Tricuspid valve and percutaneous approach: No longer the forgotten valve!

Predictive value of the TRI-SCORE for in-hospital mortality after redo isolated tricuspid valve surgery

OBJECTIVES

The TRI-SCORE reliably predicts in-hospital mortality after isolated tricuspid valve surgery (ITVS) on native valve but has not been tested in the setting of redo interventions. We aimed to evaluate the predictive value of the TRI-SCORE for in-hospital mortality in patients with redo ITVS and to compare its accuracy with conventional surgical risk scores.

METHODS

Using a mandatory administrative database, we identified all consecutive adult patients who underwent a redo ITVS at 12 French tertiary centres between 2007 and 2017. Baseline characteristics and outcomes were collected from chart review and surgical scores were calculated.

RESULTS

We identified 70 patients who underwent a redo ITVS (54±15 years, 63% female). Prior intervention was a tricuspid valve repair in 51% and a replacement in 49%, and was combined with another surgery in 41%. A tricuspid valve replacement was performed in all patients for the redo surgery. Overall, in-hospital mortality and major postoperative complication rates were 10% and 34%, respectively. The TRI-SCORE was the only surgical risk score associated with in-hospital mortality (p=0.005). The area under the receiver operating characteristic curve for the TRI-SCORE was 0.83, much higher than for the logistic EuroSCORE (0.58) or EuroSCORE II (0.61). The TRI-SCORE was also associated with major postoperative complication rates and survival free of readmissions for heart failure.

CONCLUSION

Redo ITVS was rarely performed and was associated with an overall high in-hospital mortality and morbidity, but hiding important individual disparities. The TRI-SCORE accurately predicted in-hospital mortality after redo ITVS and may guide clinical decision-making process (www.tri-score.com).

Tricuspid valve replacement: The old and the new

Tricuspid regurgitation is a frequent and serious condition but tricuspid valve (TV) surgery, that may be a valve replacement when a repair is not feasible, is rarely performed. Recent development of transcatheter TV interventions offers new options for those high-surgical risk patients, especially TV replacement for patients who are not eligible for transcatheter TV repair. In this review, we describe indications and outcome after surgical TV replacement, and devices available or in development for transcatheter TV replacement.

3D localization of vena contracta using Doppler ICE imaging in tricuspid valve interventions

Purpose

Tricuspid valve (TV) interventions face the challenge of imaging the anatomy and tools because of the ‘TEE-unfriendly’ nature of the TV. In edge-to-edge TV repair, a core step is to position the clip perpendicular to the coaptation gap. In this study, we provide a semi-automated method to localize the VC from Doppler intracardiac echo (ICE) imaging in a tracked 3D space, thus providing a pre-mapped location of the coaptation gap to assist device positioning.

Methods

A magnetically tracked ICE probe with Doppler imaging capabilities is employed in this study for imaging three patient-specific TVs placed in a pulsatile heart phantom. For each of the valves, the ICE probe is positioned to image the maximum regurgitant flow for five cardiac cycles. An algorithm then extracts the regurgitation imaging and computes the exact location of the vena contracta on the image.

Results

Across the three pathological, patient-specific valves, the average distance error between the detected VC and the ground truth model is \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$({1.22 \pm 2.00})$$\end{document}(1.22±2.00)mm. For each of the valves, one case represented the outlier where the algorithm misidentified the vena contracta to be near the annulus. In such cases, it is recommended to retake the five-second imaging data.

Conclusion

This study presented a method for ultrasound-based localization of vena contracta in 3D space. Mapping such anatomical landmarks has the potential to assist with device positioning and to simplify tricuspid valve interventions by providing more contextual information to the interventionalists, thus enhancing their spatial awareness. Additionally, ICE can be used to provide live US and Doppler imaging of the complex TV anatomy throughout the procedure.

Relationships between coronary arteries and atrioventricular annuli: surgical and percutaneous implications

OBJECTIVE

Atrioventricular valve surgery poses a risk of myocardial infarction due to the proximity of the coronary arteries. Percutaneous techniques also present a risk of coronary injury. Our objective was to identify, on the mitral and the tricuspid annuli, the zones of high risk given their proximity to the circumflex artery and the right coronary artery, respectively.

METHODS

We dissected the courses of the circumflex artery and the right coronary artery in 25 explanted hearts. The distances were measured at reference points according to a clock-face model. Proximity was "very high", "high", or "relative" for distances of less than 5 mm, between 5 and 10 mm, or more than 10 mm, respectively.

RESULTS

The mitral annulus zone of "high" proximity was located between "7:30" and "10:00" (minimum 6.5 mm at "9:30"). The tricuspid annulus zone of "very high" proximity was located between "1:30" and "3:00" (minimum 4.0 mm at "2:00"). The circumflex artery seemed closer to the mitral annulus in the hearts with left coronary dominance (n = 2), emphasizing the importance of the preoperative coronary angiography.

CONCLUSIONS

Zones at risk of coronary damage were identified on the mitral and the tricuspid annuli between "7:30" and "10:00", and between "1:30" and "3:00", respectively. Knowing them can help interventionists avoid ischemic complications. Based on an innovative clock-face orientation scheme in which the distance data were collected at multiple reference points on a superimposed template, our study provides an intuitive and detailed overview of the critical distances between valves and arteries.

Tricuspid regurgitation is associated with increased mortality independent of pulmonary pressures and right heart failure: a systematic review and meta-analysis

Aims

To undertake a systematic review and meta-analysis to determine the influence of tricuspid regurgitation (TR) severity on mortality.

Methods and results

We performed a systematic search for studies reporting clinical outcomes of patients with TR. The primary endpoint was all-cause mortality and secondary endpoints were cardiac mortality and hospitalization for heart failure (HF). Overall risk ratios (RR) and 95% confidence intervals (CIs) were derived for each endpoint according to the severity of TR by meta-analysing the effect estimates of eligible studies. Seventy studies totalling 32 601 patients were included in the analysis, with a mean (±SD) follow-up of 3.2 ± 2.1 years. Moderate/severe TR was associated with a two-fold increased mortality risk compared to no/mild TR (RR 1.95, 95% CI 1.75-2.17). Moderate/severe TR remained associated with higher all-cause mortality among 13 studies which adjusted for systolic pulmonary arterial pressures (RR 1.85, 95% CI 1.44-2.39), and 15 studies, which adjusted for right ventricular (RV) dysfunction (RR 1.78, 95% CI 1.49-2.13). Moderate/severe TR was also associated with increased cardiac mortality (RR 2.56, 95% CI 1.84-3.55) and HF hospitalization (RR 1.73, 95% CI 1.14-2.62). Compared to patients with no TR, patients with mild, moderate, and severe TR had a progressively increased risk of all-cause mortality (RR 1.25, 1.61, and 3.44, respectively; P < 0.001 for trend).

Conclusions

Moderate/severe TR is associated with an increased mortality risk, which appears to be independent of pulmonary pressures and RV dysfunction.

Transcatheter therapy for tricuspid regurgitation: The surgical perspective

Tricuspid regurgitation (TR) remains a complex valve pathology affecting nearly two million people in the United States. Although it can present as a primary valve pathology, TR often presents as a late finding in patients with severe pulmonary disease or end-stage chronic heart failure. Surgical repair of isolated TR or TR from left-sided pathology has been associated with high morbidity and mortality. Furthermore, surgery for patients with TR and advanced cardiac disease has been associated with poor long-term outcomes. In recent years, transcatheter technology has emerged to target high-risk surgical patients with TR. Currently, multiple new transcatheter strategies to treat TR have shown initial benefit. However, further development of this technology is required. The aim of this perspective is to provide an overview of TR pathophysiology and to highlight the successful aspects of surgery for TR that provide insight for further translation of transcatheter strategies for patients with TR. These include replication of successful surgical techniques (ring-based annuloplasty and valve replacement) and the goal of achieving no to minimal residual TR following intervention. Earlier implementation of transcatheter valve repair to minimize TR progression and further development of transcatheter valve replacement strategies are also next steps in the translation of this technology.

Biomechanics of the Tricuspid Annulus: A Review of the Annulus' In Vivo Dynamics With Emphasis on Ovine Data

The tricuspid annulus forms the boundary between the tricuspid valve leaflets and their surrounding perivalvular tissue of the right atrioventricular junction. Its shape changes throughout the cardiac cycle in response to the forces from the contracting right heart myocardium and the blood-valve interaction. Alterations to annular shape and dynamics in disease lead to valvular dysfunctions such as tricuspid regurgitation from which millions of patients suffer. Successful treatment of such dysfunction requires an in-depth understanding of the normal shape and dynamics of the tricuspid annulus and of the changes following disease and subsequent repair. In this manuscript we review what we know about the shape and dynamics of the normal tricuspid annulus and about the effects of both disease and repair based on non-invasive imaging studies and invasive fiduciary marker-based studies. We further show, by means of ovine data, that detailed engineering analyses of the tricuspid annulus provide regionally-resolved insight into the kinematics of the annulus which would remain hidden if limiting analyses to simple geometric metrics.

Tricuspid valve leaflet strains in the beating ovine heart

The tricuspid leaflets coapt during systole to facilitate proper valve function and, thus, ensure efficient transport of deoxygenated blood to the lungs. Between their open state and closed state, the leaflets undergo large deformations. Quantification of these deformations is important for our basic scientific understanding of tricuspid valve function and for diagnostic or prognostic purposes. To date, tricuspid valve leaflet strains have never been directly quantified in vivo. To fill this gap in our knowledge, we implanted four sonomicrometry crystals per tricuspid leaflet and six crystals along the tricuspid annulus in a total of five sheep. In the beating ovine hearts, we recorded crystal coordinates alongside hemodynamic data. Once recorded, we used a finite strain kinematic framework to compute the temporal evolutions of area strain, radial strain, and circumferential strain for each leaflet. We found that leaflet strains were larger in the anterior leaflet than the posterior and septal leaflets. Additionally, we found that radial strains were larger than circumferential strains. Area strains were as large as 97% in the anterior leaflet, 31% in the posterior leaflet, and 31% in the septal leaflet. These data suggest that tricuspid valve leaflet strains are significantly larger than those in the mitral valve. Should our findings be confirmed they could suggest either that the mechanobiological equilibrium of tricuspid valve resident cells is different than that of mitral valve resident cells or that the mechanotransductive apparatus between the two varies. Either phenomenon may have important implications for the development of tricuspid valve-specific surgical techniques and medical devices.

Prevalence and Outcomes of Isolated Tricuspid Valve Surgery Among Medicare Beneficiaries

We sought to characterize the clinical outcomes and to identify predictors of mortality undergoing isolated tricuspid valve surgery in the United States. We identified 5,164 patients undergoing isolated tricuspid valve surgery from the Centers for Medicare and Medicaid Services Medicare Provider Analysis and Review data between January 2003 and December 2014. The primary outcome was all cause 1-year mortality. A backward elimination method was performed to identify predictors of 1-year mortality. Tricuspid valve repair was performed in 2,494 (48.3%) patients and tricuspid valve replacement was performed in 2,670 (51.7%) patients. Perioperative and 1-year mortality rates were 9.9% and 24.1%, respectively. Predictors of 1-year mortality were age (p <0.001), chronic heart failure (p = 0.001, cirrhosis (p <0.001), carcinoid syndrome (p <0.001), chronic kidney disease (p = 0.001), secondary pulmonary hypertension (p = 0.023), endocarditis (p = 0.005), decubitus ulcer (p <0.001), malnutrition (p <0.001), replacement (p = 0.013), emergency procedure (p <0.001), and preprocedural shock (p <0.001). The C-statistic for 1-year mortality was 0.70 (95% confidence interval, 0.67 to 0.73). In conclusion, isolated tricuspid valve surgery is infrequently performed in the United States, and is associated with high 1-year mortality. Patients at higher risk for mortality can be identified based on the presence of a number of comorbidities at the time of surgery.

Ex vivo hydrodynamics after central and paracommissural edge-to-edge technique: A further step toward transcatheter tricuspid repair?

OBJECTIVES

Transcatheter approaches in heart valve disease became tremendously important and are currently established in the aortic position, but transcatheter tricuspid repair is still in its beginning and remains challenging. Replicating the surgical edge-to-edge technique, for example, with the MitraClip System (Abbott Vascular, Santa Clara, Calif), represents a promising option and has been reported successfully in small numbers of cases. However, up to now, few data considering the edge-to-edge technique as a transcatheter approach are available. This study aims to determine the ex vivo hydrodynamics after the central and paracommissural edge-to-edge technique in different pathologies.

METHODS

Because of basal or apical dislocation of papillary muscles, leaflet prolapse or tethering was simulated in porcine tricuspid valves mounted on a flexible holding device. Central and paracommissural edge-to-edge techniques were evaluated successively in these pathologies. Regurgitant volume and mean transvalvular gradient were determined in a pulse duplicator.

RESULTS

In this ex vivo model, the isolated edge-to-edge technique reduced tricuspid regurgitation. In the prolapse model, regurgitant volume decreased significantly after central edge-to-edge technique (from 49.4 ± 13.6 mL/stroke to 39.3 ± 14.1 mL/stroke). In the tethering model, both the central and the paracommissural edge-to-edge techniques led to a significant decrease (from 48.7 ± 13.9 to 43.6 ± 15.6 and to 41.1 ± 13.8 mL/stroke). In all cases, the reduction of regurgitant volume was achieved at the cost of significantly increased mean transvalvular gradient.

CONCLUSIONS

This study provides a reduction of tricuspid regurgitation after the edge-to-edge technique in the specific experimental setup. Whether this reduction is sufficient to treat tricuspid regurgitation successfully in clinical practice remains to be established. Transcatheter approaches need to be evaluated further, probably with regard to concomitant annuloplasty for higher reduction of tricuspid regurgitation.

Percutaneous Treatment of the Tricuspid Valve Disease: New Hope for the "Forgotten" Valve

Tricuspid valve disease is a frequent condition but is currently undertreated. A limited number of patients undergo an isolated surgical tricuspid repair, and this intervention is associated with poor outcomes, especially in patients with previous cardiac surgery. Most patients are only medically treated, despite the impact of severe tricuspid regurgitation on functional status and long-term survival. Transcatheter therapies represent a promising alternative for patients with severe tricuspid regurgitation and high surgical risk. In the last few years, several percutaneous alternatives have been developed for the treatment of functional tricuspid regurgitation. Imaging techniques play an indispensable role in patient selection, procedural guidance and follow-up. The current available transcatheter options for native tricuspid valve disease can be divided into 3 main groups: heterotopic caval valve implantation, annuloplasty devices, and coaptation devices. In patients with previous tricuspid valve surgery, transcatheter valve-in-valve and valve-in-ring procedures have been reported. This review provides a detailed analysis of the novel transcatheter alternatives for the treatment of tricuspid valve disease that have already been successfully implanted in humans, as well as the most important aspects of tricuspid valve anatomy and imaging assessment.

Suture Dehiscence in the Tricuspid Annulus: An Ex Vivo Analysis of Tissue Strength and Composition

BACKGROUND

Surgical repair of functional tricuspid regurgitation (FTR) is an increasingly common practice, but annuloplasty suture dehiscence remains a significant problem. Quantitative and mechanistic understanding of annular suture holding strength can support more effective techniques for tricuspid valve device anchoring.

METHODS

Suture holding strength of ovine tricuspid annuli (n = 15) was quantified ex vivo by pullout testing at 12 positions around their circumference. Collagen density in additional annuli (n = 7) was quantified at positions above each commissure and midleaflet point by two-photon autofluorescence microscopy, enabling mechanistic assessment of its role in imparting suture holding strength to the tissue.

RESULTS

Suture holding strength from pullout testing varied significantly by annular position, with a maximum of 10.0 ± 4.1 N at the septal leaflet (6 o'clock) and a minimum of 4.3 ± 1.3 N at the posterior leaflet (1 o'clock). Leaflet midpoints showed significantly higher annular tissue strength than commissures (7.2 ± 3.4 N versus 5.6 ± 2.1 N, respectively, p = 0.008). Collagen density, measured by a normalized mean pixel intensity, was significantly higher in the septal annulus than in the posterior-septal commissure, posterior annulus, and anterior-posterior commissure. Suture holding strength showed a strong linear correlation with collagen density (R² = 0.822, p = 0.013).

CONCLUSIONS

The clinical predominance of suture dehiscence at the septal annulus, despite its greater ex vivo holding strength, suggests either adverse suture placement techniques in this region or asymmetric tensile loading after implantation. This issue highlights the need to optimize implantation techniques and to carefully assess anchor security in existing and next-generation FTR corrective devices.

Transcatheter tricuspid valve-in-valve replacement: one-year results : Alternative to surgery in high-risk patients

Although rheumatic heart disease is becoming uncommon in industrialized countries, its global burden is still significant. We report the case of a 70-year-old male with rheumatic heart disease, who underwent 4 previous heart valve replacement surgeries, and presented to our hospital with refractory heart failure (NYHA functional class IV) due to severe stenosis of a previously implanted tricuspid bioprosthesis. The Heart Team deemed the patient as inoperable/high-risk for surgery. As an alternative, a transcatheter tricuspid valve-in-valve replacement was decided upon and later executed through the right femoral vein, with the insertion of an Edwards SAPIEN XT 29 no. (Edwards Lifesciences, Irvine, CA, USA) through the inferior vena cava, towards the RV, followed by direct implantation in the tricuspid bioprosthesis (valve-in-valve), under rapid pacing, without complications. A substantial clinical and echocardiographic improvement was noted after the procedure and the patient was subsequently discharged in NYHA functional class II. These favourable outcomes persisted through the 1-year follow-up period. This case report adds to the current body of evidence that tricuspid valve implantation stands as a viable and reliable alternative in the treatment of degenerated bioprosthesis in high-surgical-risk patients.